Healthcare Provider Details

I. General information

NPI: 1487636213
Provider Name (Legal Business Name): MINNESOTA STATE COLLEGES AND UNIVERSITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CARKOSKI CMNS MINNESOTA STATE UNIVERSITY, MANKATO
MANKATO MN
56001-6030
US

IV. Provider business mailing address

21 CARKOSKI CMNS 600 MAYWOOD AVE
MANKATO MN
56001-6030
US

V. Phone/Fax

Practice location:
  • Phone: 507-389-2483
  • Fax: 507-389-2206
Mailing address:
  • Phone: 507-389-2483
  • Fax: 507-389-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number200808
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANN JOHNSON
Title or Position: PHARMACY MANAGER, PIC
Credential: BS
Phone: 507-389-2483